The Case Against Active Surveillance or Watchful Waiting For Prostate Cancer

October 24, 2017 8:35 am Published by

By: Robert Pugach, MD

I write this article with two very interesting perspectives and viewpoints. Firstly, I am a urologist. I treat a lot of prostate cancer. In fact, I have one of the largest prostate cancer practices in The
United States. I regularly see patients from all over our state, from other states and from countries throughout the world.

Secondly, I am a prostate cancer survivor.

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I was diagnosed with cancer late last year. In May of this year, I underwent a urethral sparing HIFU procedure and I am now cancer free.

For many years, there has been a movement to not treat all prostate cancers. The reason is that there are many men whose cancer will never grow to the point where it will metastasize (spread to other parts of the body) or cause death. The movement to not treat has now expanded to not even diagnosing prostate cancer. The result is that there are now potentially millions of men with prostate cancer who either don’t know they have it or are allowing it to grow and spread.

Why has the movement to not treat grown? The answer is, quite simply, that the results of the two traditional treatments – radical surgery or radiation – can have significant, life-changing side effects that negatively impact a person’s daily quality of life. The worst one is permanent urinary leakage that requires constant use of absorbent pads or diapers. This occurs in 35% – 50% of treated men. The second dreaded side effect is erectile dysfunction (ED). The incidence of this varies depending upon the extent of cancer in the prostate but it’s safe to say that at least 50% of men lose the ability to have spontaneous erections. The unfortunate truth is that the newest surgical technique – robotically assisted laparoscopic surgery – has not changed these statistics to a significant degree.

Radiation is available in many forms. The most common ones are Protons, radioactive seeds (brachytherapy), high dose radioactive rods, gamma knife, conformal therapy and IMRT. Most will give a good result for 5-6 years but that’s when the recurrences start. The sad truth is that estimates are that up to 60% of patients will fail radiation treatment. A good example of this is our governor, Jerry Brown. Governor Brown’s prostate cancer was treated with radiation in 2012. Now, newspapers report his cancer has re-occurred. While reports say he’ll have more radiation, that won’t cure his cancer. Firstly, he cannot have a significant amount of radiation because he’s already received close to the maximum allowable dose. Secondly, why would he have the same treatment that has already failed?

With all of this as background, here are my thoughts about what a patient should do. They are not just words from a doctor; they are words from someone who did what I’m about to say.

We need to understand that prostate cancer is CANCER. It is not necessarily a slow-growing tumor located in the prostate. It has the potential to spread locally and obstruct the ureters that carry urine from our kidneys to the bladder. It has the potential to grow into the bladder and cause significant bleeding. It has the potential to metastasize to other areas. The most common site of metastasis is to the bones. These metastases are extremely painful. If the vertebral bodies that surround the spinal cord are affected paralysis can result. Once again, prostate cancer is CANCER!

As with any cancer, early diagnosis is the key to a successful treatment outcome. That’s why PSA testing is so important. That’s how my cancer was diagnosed. My prostate examination was completely normal. So was an MRI of my prostate. But my PSA was abnormal. Actually, the total PSA level was normal at 1.1. But the free PSA fraction (that’s the part of PSA not tied to proteins in your bloodstream) was low. It should be more than 25%; mine was 18%. This is important – always request that your doctor order both a total and free PSA. If I had not had a free PSA my prostate cancer would not have been diagnosed and it would still be growing inside me.

The next step was a biopsy. Many people fear biopsies. It’s an uncomfortable procedure. There’s a chance of infection afterwards. But, with a properly done nerve block and proper antibiotic prophylaxis, the chance of pain or infection is minimal. Some men fear that a biopsy may spread cancer. While that’s never been documented after decades of biopsies of prostates and many other parts of our bodies (breast, lung, bone, lymph nodes, etc.), the obvious question is: what is the alternative? We cannot diagnose cancer without a biopsy. So, if you don’t have one, and you have cancer, you are allowing it to grow and spread. That makes no sense.

When my cancer was diagnosed I wanted it treated in a way that would not leave me with serious side effects. I wanted to be “whole” afterwards. That’s why I chose HIFU – High Intensity Focused Ultrasound. With HIFU, we finally have a treatment that can cure cancer with a markedly reduced potential for the side effects seen with surgery and dramatically fewer recurrences than radiation. Instead of the 35% – 50% incidence of urinary incontinence seen after surgery, there is a 3% chance with HIFU. Instead of a 50% or greater likelihood of ED HIFU has a 5% incidence.

In the weeks leading up to my treatment, I was surprisingly calm. I can honestly say that I never had a moment of fear, anger, panic or any of the other emotions that many of my patients have shared with me in over 30 years of treating this potentially lethal, terrible disease.

The reason for my attitude was that my cancer was diagnosed at the earliest possible stage. The odds were overwhelmingly likely that it would never return. That meant that I was in charge of my cancer instead of it being in charge of me. I was spared the fear that patients experience when they are diagnosed with advanced prostate cancer that can be extensive or aggressive and, potentially,
not curable.

I was also calm because I had the utmost confidence in my doctor. Like me, he had been traveling to other countries for the past 10 years treating patients with HFIU. I knew he was experienced and that I was in good hands.

On Tuesday, May 9, I had my HIFU treatment. I had worked a full day in my office the day before. The anesthesiologist gave me some oxygen to breathe as I drifted off to sleep. My procedure lasted about 3 hours. My HIFU doctor told me that the procedure went perfectly. That evening, I was at a urology dinner meeting enjoying a steak and a glass of wine. Other than some discomfort from a urinary catheter, I had no pain.

I arrived for my HIFU treatment with prostate cancer. Several months later my PSA is excellent and indicates that I am cancer free. I do not have the side effects of radical surgery. I did not go through weeks of radiation therapy wondering afterward if I would be in the large group of men with recurrent cancer. I don’t wake up each day worrying whether or not I should have treatment for my prostate cancer. I am whole and back to a normal life. In fact, I was back to normal activities 3 days after my procedure.

The key to successful treatment of prostate cancer is to have it diagnosed at its earliest stage so treatments like HIFU are a viable option. I can tell you now, from my personal experience, that it’s the key to getting on with your life while leaving you whole.

Pacific Coast Urology Medical Center and Western States HIFU is one of the leading medical practices in the US specializing in diagnosis and treatment of prostate cancer. Call 844-HIFUDOC (443-8362) or visit: and

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